2.17: Insomnia

Question 1

What should be explored before sleeping pills?

Answer 1

1. Cognitive behavioral therapy

2. Sleep hygiene

Question 2

Some curable causes of insomnia?

Answer 2

1. Substance abuse
2. Psychiatric illness
3. Medical illness
4. Restless leg syndrome

Question 3

Medication categories for insomnia?

Answer 3

1. Benzodiazepines
2. Non-benzodiazepine agonists
3. Melatonin receptors agonists
4. Antihistamines
5. Herbal preparations

Question 4

Which approved benzo is most often used for insomnia?

Answer 4

1. Temazepam

2. Lorazepam: often prescribed but not approved for insomnia

Question 5

For how long a duration should benzos be used for insomnia?

Answer 5

Should try to hot have patient on them for > 1 week

Question 6

Which benzos should be used in elderly?

Answer 6

“LOT”

1. Lorazepam
2. Oxazepam
3. Temazepam
   * **No active metabolites as they do not undergo phase I metabolism

Question 7

What is rebound insomnia?

Answer 7

• When you stop taking the benzo, you will again have insomnia and often worse

Question 8

Who is at low risk for abuse of benzos?

Answer 8

• Patients with anxiety disorders as they are often already anxious about becoming addicted to them

Question 9

Which are the Imidazopyridines?

Answer 9

1. Zolpidem

2. Zaleplon

Question 10

Which are the Pyrrolopyridines?

Answer 10

2.Eszopiclone

Question 11

What has the side effect of sleep walking/talking/driving?

Answer 11

Non-benzodiazepine agonists:

1. Zolpidem
2. Zaleplon
3. Eszopiclone

Question 12

What is the problem with Non-benzodiazepine agonists?

Answer 12

Sleep walking, talking, driving

Question 13

What is the problem with Ramelteon?

Answer 13

Very expensive

Question 14

What are the antihistamines that can be used for insomnia? Which is best for use in the elderly?

Answer 14

1. Cyclobenzaprine
2. Diphenhydramine
3. Hydroxyzine: Best for elderly as NOT muscarinic

Question 15

What is Valeriana?

Answer 15

Herbal medication for insomnia

Question 16

How does Valeriana work?

Answer 16

Sesquiterpenes: compounds that mediate GABA release & inhibit GABA breakdown

Question 17

Benefits of vererian?

Answer 17

1. No hangover
2. Now aversive effects
3. No DDIs

Question 18

Draw back of valerian?

Answer 18

Only effective for 4 weeks

Question 19

How does chamomile work?

Answer 19

Contains Apigenin, a benzodiazepine agonist

Question 20

What is KAVA

Answer 20

• Contain compounds that facilitate binding of GABA

- Reported to have calming effects

Question 21

What is Passion flower?

Answer 21

• Reported to be effective & safe but unsubstantiated

- Chrysin is active ingredient: benzodiazepine partial agonist

Question 22

What are the OTC sleep aids? How do they work?

Answer 22

1. Unisom - contains doxylamine (antihistamine)

2. ZzzQuil - contains diphenhydramine (antihistamine)

Question 23

MOA of buspirone?

Answer 23

5HT-1a partial agonist

Question 24

DDi of buspirone?

Answer 24

DO NOT USE with MAOI: serotonin syndrome

Question 25

Clinical use of buspirone?

Answer 25

1. Generalized anxiety disorders | 2. Adjunct with antidepressants

Question 26

What are the advantages of buspirone over benzos?

Answer 26

1. No dependance 2. No withdrawal 3. No GABA cross tolerance

Question 27

What are the advantages of buspirone over antidepressants?

Answer 27

1. No sexual side effects 2. No weight gain 3. No withdrawal